We’re happy to check your dental benefits. Please provide the following and we’ll get back to you promptly:
Policy Holder Name
*
First
Last
Policy Holder Date of Birth
*
-
Month
-
Day
Year
Date
Patient Name
*
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
Insurance Provider
*
Employer or Plan Name
Member ID or SSN
*
Group #
Insurance Provider Phone Number
*
Submit
Should be Empty: